Melanie Cole, MS (Host): Welcome to UAB Medcast. I'm Melanie Cole and joining me today to highlight Telehealth and Diabetes is Dr. Anish Patel. He's an Endocrinologist with UAB Medicine. Dr. Patel, thank you so much for joining us today. How has healthcare shown telehealth efficiency, changing the care paradigm to the home, decreasing hospitalizations and readmissions?

Since the pandemic, we have sort of learned a lot about ways that we can utilize this amazing resource. Tell us a little bit about the evolution.

Anish Patel, M.D.: Telehealth's been around for quite some time in different kind of formats. We think of it in three different ways. So you can have synchronous telemedicine where we just have a real time appointment. You have asynchronous telemedicine where you get medical data from the patient and they transmit it later for assessment.

Or you can have remote monitoring, which is previously what the bulk of telemedicine was where basically you have health data that's either continuous collected by the patient, like continuous glucose monitors or remote patient blood pressure monitoring that they would send to us and we would look at on the backend.

But since the pandemic, it's expanded and expedited how quickly we utilized telehealth and especially here at UAB, we were one of the early adopters of this because we already had a pre existing program and we were able to expand and make it so that we could really get a lot of patients access to us through the pandemic with telehealth and prevent those hospitalizations that may have otherwise happened with heart failure or diabetes and hyperglycemia,

or very common things helped avoid the emergency room and admissions because people were avoiding going to primary care during that time frame. So by getting into at least talk with one of their physicians, they could stave off fluid overload with extra Lasix if they needed it, or, get their sugars better controlled so they didn't have to go to the ER.

Host: Yeah. It's such an interesting topic we're discussing today. So when we're thinking specifically of diabetes, how much does a healthcare provider rely on patient provided data when it comes to managing diabetes? As we think of telehealth and these visits you're talking about and how much they've helped, especially in rural areas, more access to specialists without having to travel.

How much do you rely on what they are telling you in technology that is then coming to you also via telehealth.

Anish Patel, M.D.: So, especially with diabetes this is a lot of patient driven data that we need. And when we see patients in the clinic, if they aren't bringing their glucose monitor, or their glucose logs or even have a recollection of t,heir what their sugars are doing, the use, the usefulness of the visit decreases drastically.

And the way that telehealth has really helped us in this regard is that if the patient's at home, they have access to all of these things very easily. So they can go grab their monitor from their bathroom and get it out in front of us and kind of just read out what the numbers are rather than them coming to clinic and not remembering a single thing. And then we're making adjustments on a gestalt of how the patient feels their sugar is doing and the only real data that we have is the finger stick we do in clinic and maybe the A1C if we get it back in time. So having that ability for the patient to go grab their log at their own house, grab their glucose monitor, can really increase the effectiveness of the visit greatly. And then with other technologies that we have available nowadays, including continuous glucose monitoring, that can just be skyrocketed in terms of how much data we have to look at to really help someone.

Host: So tell us a little how it actually works as far as patients sharing their glucose monitor data with providers. Are you able to have models to help your staff upload these tools to look at the insulin pump data and the continuous glucose monitoring data? How does that all work?

Anish Patel, M.D.: Yeah, so we actually do look at insulin pump data and continuous glucose monitoring data, on the regular. So most of our patients who are on multiple daily injections of insulin, we try to get them a continuous glucose monitor providing insurance coverage, is available, and on their first visit, usually we're seeing them in clinic, and we'll get them set up with certain monitors have certain programs that are associated with it.

So the Dexcom system has the Clarity app and the Clarity website where it's kind of cloud based data. So most of these systems have cloud based data and basically the patient has their own account and the clinic has their own account. And we tell the patient, okay, here's our clinic code. You put this into your app on your phone or on the computer, and it allows us access to their cloud data to pull all the sugars off of there.

So it's pretty instantaneous. I mean, it, it takes a couple of minutes to set up as long as everyone's somewhat computer savvy and phone savvy. If not, we usually get the patient into our diabetes educators and have them connect the two accounts together and link them so that we can download the data readily.

And it doesn't even require the patients to actually contact us. We can pull it before their appointment the day before. That way we have it ready to go when we're doing either our telehealth visit or our in person visit, and we have time to review everything. So it's very nice. And that applies to insulin pumps as well.

Host: How does it impact your decision making, Dr. Patel, or change it? If you're seeing someone's information come through on your modules and, you're getting these technology, these tools that are really advancing diabetes care, and you're having telehealth visits, which I mean are amazing because not only can you talk to the patient and get their real time data, but you can also see maybe their home situation, which is something that you might not have been able to see, or that you are going to be able to see them in a different situation than when they're sitting there nervous in your office. How has this, do you feel in your opinion, changed your decision making process?

Anish Patel, M.D.: I think it's given me a better perspective on kind of the social determinants of health with some of my patients. You know, you can't really assume anything when they're coming into clinic, but when you can actually see their home life and you can see what their living situation is, sometimes it, it may make you think twice about doing a certain intervention when it may not be feasible for them. Like if they don't have access to a full kitchen or something like that, then maybe some of these interventions for lifestyle aren't really appropriate or not possible for this patient. Or if, you know, they got seven, eight children running around at home, because they're taking care of a lot of kids, then they may not have the time to worry about their own meals. So, I think it's played a big role in, in how we go about targeting our interventions and trying to tailor it better to the patient's situation in their home life.

So, I think that's been a big improvement in, in terms of how we take care of our patients, is we can get a better context of how they live and what is maybe more likely to be efficacious.

Host: One of the things that I found most interesting, Dr. Patel, about telehealth in general and across the board, is providers were in a silo, in their office with their patients, but now research, outreach, provider collaboration, opportunities for growth and new research being shared and telemedicine and the modules and the data being able to be shared with other providers that are working with that same patient.

What do you think about how this has really changed the whole landscape of not only diabetes care but medicine in general?

Anish Patel, M.D.: Well, I think it's definitely opened up opportunities between specialties. It's a lot easier for say a nephrologist to look at some of this data that they get in terms of blood pressure monitoring, see that there's a problem and either let us know or vice versa. We let them know that this patient's having trouble with their blood pressure control. And so we can collaborate a lot easier. And, from the diabetes standpoint, cause that's what I do, we have a working relationship with our maternal fetal medicine practice and OB, that if we don't have availability, the MFM clinic will see the patient, but they're able to also access the patient's continuous glucose monitor data, download it, make changes, tell us about it so that we can review it and maybe get a closer follow up.

So I think the opportunities for collaboration between specialties has really increased with telehealth and the amount of data that's just available and it's available to everybody can just be helpful for the patient.

Host: Yes. What an exciting time for this type of medicine. As we wrap up, Dr. Patel, tell us some of the key learnings you think other providers should know if they're going to go about setting up their practice for telehealth with patients living with diabetes.

Anish Patel, M.D.: So I think there's several things that you have to keep in mind when you're setting up a telemedicine practice. Often it can be difficult to work in telemedicine visits in an inpatient clinic visit day.

 So sometimes it's better to have a separate time frame where you're just doing telehealth. That way you can just hammer it all out at once and you don't have to worry about technical difficulties switching between an in person visit and a telehealth visit. So that's it. Making sure that you can set aside time or that you have everything ready to go when you're doing telehealth visits can be helpful.

And then it may be useful for you to see the patient in person at least once. That way you can assess their digital literacy and make sure they're capable of getting on the video conference or uploading their data and kind of seeing if they're comfortable with the idea of doing telehealth to make a more fruitful visit.

And then there's also other things you have to consider, if they're in a rural area and have limited access to the internet, you may want to consider these patients not suitable for telehealth visits. But usually they can get to somewhere where they can get some cellular service. So I think just kind of keeping that cultural competency in mind when you're thinking about setting up patients for telehealth is important.

And then making sure you have all of the programs and the data analysis software available to yourself that you can upload the continuous glucose monitor and be able to visualize the data with some of the programs available. That way you can make a fruitful visit.

Host: Thank you so much, Dr. Patel for joining us today and for more information, you can visit our website at uabmedicine.org/physician. That concludes this episode of UAB Medcast. I'm Melanie Cole. Thanks so much for joining us today.